Compositions and methods of using corticosteroids and thiamine derivatives



United States Patent 3,284,304 COMPOSITIONS AND METHODS OF USING COR- TICOSTEROIDS AND THTAMINE DERTVATHVES Jean Montandraud, Casablanca, Morocco, assignor to Societe dApplications Chimiques, dEtudes & de Recherches S.A.C.E.R., Monte Carlo, Monaco No Drawing. Filed June 5, 1962, Ser. No. 200,050 Claims priority, application Great Britain, June 21, 1%1, 22,357/61 4 Claims. (Cl. 16777) The present invention relates to a group of compositions for therapeutic usage presenting, relatively to their constituents which are individually well known and used, new and unexpected favourable effects. From their more general aspect, these compositions may be designated by the generic term of the compounding or other association of at least one corticosteroid with at least one thiamine derivative.

By corticosteroids are understood derivatives of the cortisone type, such as cortisone itself, hydrocortisone, deltacortisone or prednisone, delta hydrocortisone or prednisolone and derivatives thereof, such as the ftuoric derivatives of cortisone, whether these compounds are of natural or synthetic origin.

By thiamine derivatives are understood thiamine itself, thiamine hydrochloride, phosphoryi-thiamine and the like derivatives, including these having an open thiazol cycle, such as diacetylthiamine, dithiopropylthiamine or its hydrochloride and the like.

For greater convenience, in the following description of the invention, reference will be made to cortisone and thiamine, but the invention also covers compounds or associations of other derivatives of cortisone with other derivatives of thiamine, since experience has shown that the nature and the degree of the phenomena resulting from the association of these derivatives are of the same order of importance relative to the individual effects of the constituents of each association studied. Again wherever the term compound or the term association is used herein, reference to both is implied.

The individual effects of cortisone and thiamine are generally known and each of these compounds already has a wide field of application.

However, the undoubtedly useful effects of cortisone are always accompanied by side effects on the patient, the nature and mechanism of these side effects still being very insufficiently understood, but which are generally indicated as a whole by symptoms of asthenia and fatigue, nervous troubles such as insomnia and even a reducing of the muscles.

Ln the course of clinical experiments on an appreciable number of patients treated with cortisone (and its derivatives) the surprising discovery was made that the replacement of cortisone by a cortisone-thiamine compound or association (or a cortisone-thiamine derivative) gives rise to an improvement in the general condition and bearing of patients, this improvement being particularly noticeable in respect of feelings of debility and reduced resistance to effort which disappear to a very large degree.

As such an improvement can only be appreciated subjectively, it has been considered necessary to check it by quantitative pharmacological experiments. These experiments have completely confirmed the clinical discoveries, as will hereinafter be described in greater detail.

Thus the invention concerns the field of medical preparations responding to the general indications of cortisone and its derivatives, but due to which astheniant and hypoxiant side effects of cortisone are eliminated. The compounds consist of at least one derivative of cortisone and at least one thiamine derivative; the relative proportions of each constituent of these compounds may also vary within very wide limits; again the favourable effects of the association of thiamine with steroid substantially in the proportion of 1:5 by weight have been discovered, as also are compositions containing steroid and thiamine substantially in the proportion of 1:50 by weight. Thus the range of proportions of steroid to thiamine may be from 5:1 to 1:50.

in practice the preferred proportion is one part by weight of steroid for five parts by weight of thiamine, for example, 10 mg. of cortisone and 50 mg. thiamine. These proportions are intended for daily doses to be administered to human patients.

The circumstances and the results of studies on animals will now be described, these studies having confirmed quantitatively the clinical observations which led to the invention.

These studies refer to:

(l) The proof in the case of animals, of a measurable debilitating effect of corticosteroids, and the improvement of resistance to fatigue shown by these animals through the association of a thiamine derivative with the corticosteriod.

(2) The demonstration in the case of animals treated with corticosteroids, of a hypoxiant effect on the cardiac muscle, evaluated numerically by the increase in sensitivity to digitalis. That is to say, by the reduction in the lethal dose of these alkaloids by the corticosteroids and the return to normal sensitivity by association of the thiamine derivative with the corticosteroid.

(3) The measure of oxygen consumption by organs of animals treated respectively with cortisone alone and the cortisone-thiamine association, this measure showing that cortisone causes a diminution in oxygen consumption, whereas the thiamine-cortisone association returns tissular respiration to a normal level.

(1) STUDY OF THE CORTICOSTEROlD-THIAMINE DERIVATIVE TREATMENT IN RESPECT OF A SWIMMING TEST CARRIED OUT ON RATS It is recognised that the administration of a single dose of corticosteroid increases muscular resistance to stress. Contrary to this, removal of the suprarenal gland breaks down this muscular resistance. In the case under test, we endeavoured to show the action on muscular resistance of the repetition of the administration of corticoid to the normal animal. By muscular resistance is understood the duration of stress which a specific subject may undergo during a task such as, for example, in causing a cage to revolve or in swimming and not the appearance of the curve of fatigue on a muscle of the carcass, the action of cortisone not manifesting itself under these conditions.

This study was inspired by the classical work of Ingle and Ratsinmanga and consisted in applying the swimming test under the following conditions:

Male Wistar rats. of a weight between and 200 g.

Swimming test carried out in a tank which was 1.30 m. long, 0.60 m. wide and 0.80 m. deep, the surface of the water being agitated by a flow of compressed air so that the animals could not remain without movement on the surface of the water.

An excess weight to the order of 5% of the weight of the subject was attached to the animal. The temperature of the water was 18 (3., thus constituting an unfavourable condition for obtaining good performance, the duration of swimming being proportional to the temperature of the bath (J. Leblanc, Proc. Soc. Ext; Biol. Med, 1958- 98).

Three groups of subjects were subjected to the test. Of these the first group of rats comprised those fed under normal conditions and receiving no treatment. The second group comprised rats treated with doses of corticosteroid varying in weight from 1:5 mg. per kg. of Weight of the animal or other subject, for one week by intramuscular injection. The third group of rats were treated under the conditions of group 2 but also received a thiamine derivative (thiamine hydrochloride) in daily oral doses of 5 to 25 mg. per kg. (expressed in thiamine).

The tests were carried out in the following manner:

Test of duration of swimming for each animal and elimination of aberrant animals;

A rest of several days makes it possible to eliminate the effects of the first effort, on the one hand, and of bias on the other hand.

Then, after treatment for eight days under the above conditions, the execution of swimming tests and the observation of results obtained therein among the three groups produced the following:

Group 1 (normal control subjects: Average duration of swimming with 24 animals on the first day, 14 minutes, with a difference of 6 minutes in the times of performance of the 24 animals.

Average duration of swimming with 8 animals 8 days later: 15-30, with a difference of 5-10 minutes, i.e. 15

I minutes 18 seconds with a difference of 5 minutes 6 seconds between the longest and shortest times of performance by the eight animals.

Group 2 (subjects treated with cortisone alone): Average duration of swim after 8 days treatment; the reduction, without being strictly proportional to the doses is, despite everything, a maximum with the biggest doses of cortisone employed. The average, evaluated from a group of 6 rats, was 4.25 minutes and the difference between the longest and the shortest time was 8 minutes 6 seconds.

A much bigger variation is thus achieved than with the first group.

Group 3 (subjects treated with the cortisone-l-thiamine): The average duration of swim after 8 days treatment was found to be 11.05 with a difference of 3.50 minutes.

Apart from the very large increase in the value of the swimming test, uniformity of the results can be established.

Knowing that the thiamine derivatives have no influence on the value of performance when they are administered to the normal animal (Molitor H., Fed. Proceed. 1942-1-3), there is therefore a contradicion here between the thiamine derivatives in regard to an effect following the prolonged administration of corticosteroid.

It is impossible to consider this effect as that of the resting of the suprarenal gland by the exogenous addition of corticoid, since the exogenous corticoid should, as in the case of the animal whose superinol gland has been removed, improve its performance as compared with the control. Nor does this concern the resultant of two contrary effects, namely one of decrease in resistance to stress by virtue of cortisone, and the other of increase by the thiamine derivatives, since thiamine in itself does not increase resistance to stress. The behaviour of subjects treated by the association of the two differs from that of the animals treated by one or other of the constituents.

(2) STUDY OF THE CORTICOSTEROID-THIAMINE DERIVATIVE ASSOCIATION ON THE FUNCTION OF THE CARDIAC MUSCLE This study is based on the two-fold discovery that the anoxic and ischemic heart is particularly sensitive to the action of digitalis and its derivatives (Loubatieres, Ther. 1953, XVIII) and that, on the other hand, a weak heart is strengthened particularly well by digitalis.

The measure of the notion of a standardised preparation of digitalis (appearance of abnormal electrocardiographic signs, measurement of lethal dose according to classical methods) therefore makes it possible to compare measurements of two groups of animals as regards the intensity of their cardiac operation.

The following experimental process was used for this evaluation of sensitivity to digitalis. This experiment was I conducted with groups of male and female guinea pigs of an equal number in each group of a weight between 250 and 350 g. Anaesthesia was effected by ethylurethane (1 gram of product per kilogram of weight of animal, intraperitoneal) after induction by a barbituric of short action. A canula was placed in the jugular vein. Electrodes were located on the four limbs for registration of the electrocardiogram (Racia type). The commencement of recording was 45 minutes after administration of the anaesthetic.

After checking the control electrocardiogram on a normal untreated animal, starting of continuous perfusion (Braun perfusor) of a natural digitalin solution in a dilution of 1/5000 was commenced at a speed of 0.2 cc. per minute, that is to say, 40 gamma of digitalis per minute. The electrocardiogram was taken regularly at predetermined intervals of time; perfusion was continued until the death of the animal, the test of death being the last electrocardiographic sign of cardiac function.

Three groups of animals were studied; namely:

Group (a) which contained normal control animals permitting standardisation, according to the classical method (La Barre, Arch. Int. Pharm. 1948, 56) of the digitalin solution employed;

Group (b) which included animals treated by corticoids in doses varying from 1 to 10 rng./kg., by intra-mus-cular injection, and

Group (0) which was constituted by animals treated by corticoids as for Group (b) and also receiving from 10 to 25 mg./kg. of a thiamine derivative.

The results were as follows:

In Group (a), the lethal dose of digitalin was 2.35: 0.17 mg. per kg.;

In Group (b), the lethal dose of digitalin was from 1.50:0.21 to 1.72:0.13 mg. per kg. according to the doses of corticoid employed while in:

Group (c) the lethal dose was 1.82:0.21 to 2.05:0.11 mg. per kg., according to the doses employed.

It is certain that the known variability in the appearance of electrocardiographic signs does not actually permit a real quantitative study of the phenomenon. On the other hand, the constancy of the toxic doses of digitalin (for specific conditions) makes it possible to appreciate the consequence of the variations discovered.

Since the sensitivity of a heart depends on its state of weakening (anoxia or ischemia), it is apparent that prolonged treatment with cortisone or corticoid derivatives shows an increase in sensitivity, this increase being reduced by the cortisonethiamine treatment.

In addition, an attempt has been made to study electrocardiographic disturbances on the basis of the two signs of toxicity of digitalin illustrating the condition of failing heart. These two signs are the modification of the T wave (inversion) and arrythmia. For this purpose non-anaesthetised dogs were used, receiving perfusions of digitalin and ouabain by intravenous injection.

Only clear cardiographic signs were considered (inversion of T and arrythmia). All the work was devoted to 13 dogs, some being controls, other were treated with cortisone, and the third group received the cortisone-thiamine derivative treatment. It should be noted that a certain number of animals were able to constitute their own controls, the different administrations of digitalis being effected at several days interval.

The control results were as follows:

Minimum doses causing electrocardiographic disturbances: ouabain 0.75 to 1.25 mg. per kg., digitalin 1.53 to 3 mg. per kg.

Among subjects treated with cortisone alone the extreme doses were: ouabain 0.52 to 0.93 mg. per kg., digitalin 1.10 to 2.30 mg. per kg.

Among animals receiving the cortisone-thiamine treatment the following results were obtained: ouabain 0.72 to 1.17 mg. per kg., digitalin 1.20 to 2.80 mg. per kg.

It is therefore apparent that the variations all take place in the same direction. A quantitative evaluation is not possible by this method, as indicated above, but knowing that sensitivity to digitalins is very closely proportional to the state of perfect operation of the heart, it may be concluded from these experimental facts that this perfect operation, which is disturbed by the administration of corticoids is retained when thiamine derivatives are compounded with the corticoids.

(3) STUDY OF CORTISONE-THIAM INE TREAT- MENT ON TISSULAR RESPIRATION This experiment consisted in comparing the consumption of oxygen by organs from animals treated by cortisone alone and by the cortisone-thiamine treatment.

Consumption of oxygen in 120 minutes (average out of 45 cases) Organ Animals treated Animals treated Increase, by cortisone alone by cortisone plus percent thiamine Liver 65.1 118. 5 81. 5 Brain. l 126 223 77 lat), respectively alone and associated with 10 mg./kg. of diacetyl-thiamine (per os); a third group of 15 rats is given physiologic serum, as a control. The three groups of rats are fed with the same standard synthetic diet.

The rats are weighed each morning and at the end of about one month the surviving rats are sacrified and some specific organs are weighed. Moreover measures of nitrogen elimination are conducted in the same time upon urine samples.

The results are the following:

1 total weight At the beginning of the test, the average weight of the rats is of 132 g.;

At the end of the test, the average weight of the controls is of 157 g., i.e. an increase of 18%;

The average weight of the rats receiving hydrocortisone alone is of 80 g., i.e., a decrease of 39%;

The average weight of the rats receiving hydrocortisone in association with diacetylthiamine is of 112 g., i.e. a decrease of 15% only.

It appears therefore that the association of thiamine derivative with the cortisone derivative substantially reduces the loss of weight due to the cortisone, and diminishes the increase of mortality.

2 weight of individual organ The relative weights (based upon 100 g. of animal weight) of various organs of rats in the three groups are reported in the following table;

Spleen Thymus Kidney Muscle Surrcnal Liver Group II III II III II III II III II III II III HO I-Iydrocortisone. DAT Diacetylthiamine. II 2d week.

III 3d week.

more normal appearance than those treated with cortisone alonethe coat is thicker, longer and the general appearance is that of younger animals. It therefore appears that thiamine has a particular capacity for reducing postcortisone biological disequilibrium.

These discoveries therefore entirely confirm the clinical observations on which the present invention is based.

Summarizing, the invention from one aspect comprises medical preparations responding to the general indications of cortisone and more generally of corticosteroids, but which eliminate the astheniant and hypoXiant side effects of corticosteroids by compounds or associations of at least one derivative selected from the family of corticosteroids with at least one thiamine derivative.

Subsidiary features include treatment with at least one corticosteroid and at least one thiamine derivative in the relative proportion of 7 to by weight, and preferably of one part by weight of steroid for five parts by weight of thiamine, and again a treatment of this nature in daily doses of the order of 50-500 mg.

A further illustration of the surprisingly favourable activity of the association of the invention resides in the study of the action of the cortisone derivative, administered respectively alone or in association with the thiamine derivative, upon the metabolism of the rat, such action being expressed in terms of variations of total weight of the animal, of variations of the weight of specific organs and of nitrogen elimination.

For this study two group of 15 rats each are given daily 5 mg./kg. body weight of hydrocortisone (intramuscu- From the two above tests it appears that the protection against the overall emaciation due to the hydrocortisone and which one of its major drawbacks is largely provided by the diacetylthiamine, and moreover that this efiect is of specific character, such protection being highly important for the surrenal glands, the thymus and the spleen, and almost unnoticeable for the muscle.

3 nitrogen elimination It is also recognized that hyperazoturia is a serious drawback resulting from the administration of hydrocortisone. The following table illustrates the protection provided by the diacetyl-t-hiamine against such drawback:

Nitrogen content of urine (mg./kg./24 hrs.) Group 1st week 2d week 3d week 4th week Controls 48B 560 532 490 485 663 669 730 HO plus DAT 568 842 667 558 rats as above the following variations have been noted (content in m-g./l):

While the foregoing description is based only upon animal experimentation, it must be pointed out that the clinic observations collected for two years from more than 500 cases are all consistent, in that in almost all the cases (60 to 80%) the very serious drawbacks reported above and resulting from the administration of the cortisone derivatives, and more specifically those classically imputed to a metabolic trouble and more generally a nutritional trouble, are reduced.

In that respect it has been possible clinically to establish that some thiamine derivatives are still superior to others. Thus those derivatives can be classified in 4 classes:

1st class: Vitamin B and all its acid salts, including benzoate and phosphate.

2d class: Esters of vitamin B acting more efficiently; e.g. monophosphorylthiamine.

3d and 4th classes: Open thiamine molecule, blocked by a S--S-R linkage (i.e. di-thio-alkyl-thiamines); by a -S-COR linkage (the primary alcohol group of the thiamine molecule being also esterified by the same or a different alkyl group, e.g. di-acetyl-thiamine).

The derivatives of the 3d and 4th classes are still preferable to the others, the observations upon which such a hierarchy has been established having been carried out according to the same procedures, which permits the comparison between the relative efliciency of the derivatives of the various foregoing classes. It must be Well understood that in spite of such a classification the invention lies in the use of any thiamine derivative of any class, since all those derivatives provide at various degree the same kind of protection against the undesirable side eifects of the cortisone derivatives.

What I claim is:

1. A method of counteracting the adverse side efiect of digitalis sensitivity in a subject resulting from the administration of a pharmaceutical dose of a corticosteroid, said method comprising jointly administrating to said subject together with said pharmaceutical dose of the corticosteroid a thiamine derivative in a weight ratio With said corticosteroid of between 1:5 and :1, said thiamine derivative being selected from the group consisting of thiamine, phosphoryl-thiamine, diacetylthiamine, dithiopropylthiamine, and the hydrochlorides of the same and then administering digitalis to the subject requiring same.

2. A method of counteracting the adverse side effect of reduction of tissular respiration in a subject resulting from the administration of a pharmaceutical dose of a corticosteroid, said method comprising jointly administrating to said subject together with said pharmaceutical dose of the corticosteroid a thiamine derivative in a Weight ratio with said corticosteroid of between 1:5 and 50:1, said thiamine derivative being selected from the group consisting of thiamine, phosphoryl-thiamine, diacetylthiamine, dithiopropylthiamine and the hydrochlorides of the same.

3. A composition for use in counteracting in a subject the adverse side effects of a pharmaceutical does of a corticosteroid comprising a thiamine derivative mixed with said corticosteroid for joint administration to said subject in a weight ratio of between 1:5 and 50:1, said thiamine derivative being selected from the group consisting of thiamine, phosphoryl-thiamine, diacetyl-thiamine, dithiopropylthiamine, and the hydrochlorides of the same.

4. A composition for the use in claim 3 wherein said corticosteroid is hydrocortisone and the thiamine derivative is diacetyl thiamine.

References Cited by the Examiner UNITED STATES PATENTS 2,841,527 7/1958 Freedman et al. 16777 2,970,944- 2/ 1961 Charnicki et al 16777 3,067,098 12/1962 Pool 167-77 3,105,010 9/1963 Perlman 167-77 OTHER REFERENCES Beckrnan: Pharmacology, 2nd edition, 1961, Saunders 00., Philadelphia, RM300B4, pp. 641-642.

JULIAN S. LEVITI, Primary Examiner. JAMES CACCIAPAGLIO, JR., Examiner.

E. FRANK, M. J. COHEN, Assistant Examine s. 

1. A METHOD OF COUNTERACTING THE ADVERSE SIDE EFFECT OF DIGITAILS SENSITIVITY IN A SUBJECT RESULTING FROM THE ADMINISTRATION OF A PHARMACEUTICAL DOSE OF A CORTICOSTEROID, SAID METHOD COMPRISING JOINTLY ADMINISTRATING TO SAID SUBJECT TOGETHER WITH SAID PHARMACEUTICAL DOSE OF THE CORTICOSTEROID A THIAMINE DERIVATIVE IN A WEIGHT RATIO WITH SAID CORTICOSTEROID OF BETWEEN 1:5 AND 50:1, SAID THIAMINE DERIVATIVE BEING SELECTED FROM THE GROUP CONSISTING OF THIAMINE, PHOSPHORYL-THIAMINE, DIACETYLTHIAMINE, DITHIOPYLTHIAMINE, AND THE HYDROCHLORIDES OF THE SAME AND THEN ADMINISTERING DIGITALIS TO THE SUBJECT REQUIRING SAME. 